By Public Health Expert 01/12/2020


Dr Ben Gray*

To date New Zealand has come through the pandemic well. The role of political leadership and scientific input has been well covered. Part of this success was built upon having a clear ethical framework for managing a pandemic that had been developed in advance following the SARS outbreak. This blog considers the interaction between the science the ethics and the decision makers.

In their blog post in February Cunningham et al1 drew our attention to the 2007 document “Getting through together: ethical values for a pandemic.2 This document was the result of wide consultation in Aotearoa/New Zealand following the SARS epidemic and is a good example of applied practical ethics. The norm in bioethical discussion is to debate what is normatively the right thing to do. This document tried to answer the question what we, in Aotearoa/NZ, think is the right thing to do and how is the right way to do it. It produced two tables one that outlined how we make decisions and the other on what decisions we make.

It reflected the culture and beliefs of this country and, in particular, included significant Māori concepts such as kotahitanga (unity of purpose and action), manaakitanga (is behaviour that acknowledges the mana of others as having equal or greater importance than one’s own, through expression of aroha, hospitality, generosity and mutual respect), and whānaungatanga (binds individuals to the wider group and affirms the value of the collective).3 This document was embedded in the New Zealand Influenza Pandemic Plan 20174 and thus the public servants advising government on management would have been aware of it. At the time that a pandemic strikes there is not time or resource to consult widely around decisions that need to be made so having a pre-existing document such as this can be very helpful.

In my recently published paper5 I argue that the existence of an ethical framework was an important element behind New Zealand’s successful response to Covid-19. I looked at the briefings from the Prime Minister and the Director General of Health and mapped the extent to which the approach they took aligned closely with “Getting Through Together” (see quotes). For example:

  • The team of five million is a direct reference to kotahitanga…doing this together.
  • Being kind is a reflection of manaakitanga; behaviour that acknowledges the mana [prestige] of others as having equal or greater importance than one’s own, through expression of aroha [love], hospitality, generosity and mutual respect.3
  • There has been a commitment to openness and transparency, particularly evidenced in the daily briefings during the early phase of the pandemic.

My conclusion was that “Our politicians, in particular Prime Minister, provided the leadership in making difficult decisions based on the ethical framework and scientific information, while building and maintaining the trust of the population necessary to implement them. Bioethics played an important role in eliminating COVID-19 from New Zealand.”

A central ethical value in pandemic planning is kotahitanga or solidarity. If we do not do this together, we will not get through. Clearly the lack of unity in the USA is an important element behind the way the pandemic is playing out there. This requires us to be united behind our decision makers, the politicians, even though inevitably all of us at one time or another may not agree on the decisions made. Our politicians behaving the “right way” (the way most New Zealanders think is right) will enhance trust. The New Zealand Attitudes and Values Study conducted a survey before and after the Covid-19 level 4 lockdown. It showed that trust in the police, science and politicians increased and satisfaction in the government’s performance went up significantly.6 Clearly the government and health officials managed to nurture kotahitanga during this phase of the pandemic.

One of the challenges of maintaining kotahitanga is how to manage criticism of the government approach. This was difficult for the National Party during the election campaign because on the one hand they needed to be seen as part of the “team of 5 million”, but on the other hand their job as an opposition was to point out the problems that they saw; that is the job of politicians. I am sure this tension contributed to the outcome of the election.

The role of scientists and bioethicists is different from the role of politicians/decision makers. The role of scientists is to interpret the often-uncertain knowledge that we have so that information can be incorporated into decisions. On occasions the government completely implemented the scientific advice and on other occasions they used the advice but balanced it with other considerations. The decisions on when to enter and leave the different levels of control were significantly determined by the scientific advice. By contrast the suggestion that New Zealand should build a dedicated quarantine facility at Ōhakea rather than using hotels seems unlikely to gain traction. Whilst from a public health perspective it is a good idea, other considerations are maintaining business for some hotels in the absence of foreign tourists, avoiding the costs of a dedicated facility that could well sit unused for significant time after this episode has settled, and avoiding the disruption to the air force that having such a facility on their campus would create.

The role of the scientist is to provide information, but to try to avoid criticising the decision as this can undermine solidarity. A good recent example of this was in the blog by Nick Wilson and colleagues7: “This high failure rate is unacceptable from a border control perspective…as well as from an occupational health perspective”, an opinion backed up by scientific argument. He did not say that decisions to date were wrong, although it might have been helpful to mention that there are other considerations to be considered apart from these two when reaching a decision.

Scientists give advice, but it is the politicians who are accountable for the decisions.

The National Ethics Advisory Committee (NEAC) responded to the pandemic by producing an “Ethical Framework for Resource Allocation During Times of Scarcity”.8 The central part of the NEAC document is an ethical framework on resource allocation, and they acknowledge the need to update the pandemic planning document in the light of Covid-19 experience. This is a good illustration of the role bioethicists can play. However, in addition the bioethicists on NEAC implicitly criticise those responsible for decisions on Intensive Care Unit Bed/Ventilator allocation, Personal Protective Equipment allocation and Vaccine allocation by suggesting that we need new decision making groups constituted to make these decisions. These decisions are currently made by ICU staff, the Ministry of Health staff and PHARMAC. Each of those decision-making bodies have clear reporting lines that end with the relevant ministers, who are ultimately responsible for the decisions. Many decisions are delegated to the organisations but under clear political guidance. Bioethicists contribute by describing the values that are relevant to the decisions being made, and how many of those values might compete. A good example of this is PHARMAC’s “factors for consideration”9 which has been developed over many years and much consultation. For all of these decisions the 2007 document2 provides an overall framework to work from. Like the scientists they give advice but the public servants in the particular areas will advise the politicians who are accountable for the decisions.

The politicians need to listen, be prepared to change course in light of new information and behave in a way that enhances trust. Central to maintaining trust is respecting all views, being open about how decisions are made, and being responsive when unintended consequences of decisions are brought to light.

The rest of the team of 5 million need to be kind, respectful, inclusive and be able to place the needs of the whole community above our more narrow individual needs. Political debate is essential, none of the decisions are clear cut and all ideas are helpful. Conducting the debate respectfully and being able to live with difference is essential.

New Zealand has fared better than many in the Covid-19 pandemic. The combination of a clear ethical framework, good scientific advice and skilled, trusted politicians has served us well. This has significantly contributed to the population pulling together. Maintaining kotahitanga is vital for our continuing successful response to the pandemic.

*Author Details: Primary Health Care and General Practice, University of Otago Wellington; Email: Ben.gray@otago.ac.nz

 

References

  1. Cunningham R, Paul C and Moore A. Getting Through Together: Ethical Values for a Pandemic. Public Health Expert. Wellington New Zealand: University of Otago, 2020.
  2. National Ethics Advisory Committee. Getting Through Together: Ethical values for a pandemic, http://neac.health.govt.nz/system/files/documents/publications/getting-through-together-jul07.pdf (2007, accessed 11/8/13).
  3. Public Health Association of New Zealand Incorporated. Te Ture Whakaruruhau Code Of Ethical Principles For Public Health in Aotearoa New Zealand., https://www.pha.org.nz/page-18201 (2012, accessed 28/3/13).
  4. Ministry of Health. New Zealand Influenza Pandemic Plan: a Framework for ACtion, https://www.health.govt.nz/publication/new-zealand-influenza-pandemic-plan-framework-action (2017, accessed 13/4/20).
  5. Gray B. COVID-19 from Wellington New Zealand. Journal of Bioethical Inquiry 2020: 1-6. DOI: 10.1007/s11673-020-10038-3.
  6. Sibley CG, Greaves LM, Satherley N, et al. Effects of the COVID-19 pandemic and nationwide lockdown on trust, attitudes toward government, and well-being. American Psychologist 2020.
  7. Wilson N, Grout L, Kvalsvig A, et al. Time to Stop Dodging Bullets? NZ’s Eight Recent Border Control Failures. Public Health Expert. 2020.
  8. National Ethics Advisory Committee. Ethical Framework for Resource Allocation in Times of Scarcity, https://neac.health.govt.nz/public-consultation-ethical-framework-resource-allocation-during-times-scarcity (2020).
  9. PHARMAC. Factors for consideration, https://pharmac.govt.nz/medicine-funding-and-supply/the-funding-process/policies-manuals-and-processes/factors-for-consideration/ (2020, accessed 17/11/20).

*Image by Gerd Altmann from Pixabay 

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